The death of a fighter

Two deep gasping breaths, then stopped as I entered the room. The woman sitting by his bedside turned to me and with anguish said,  “There, he just stopped. He just took his last breath.”  The grandfather wall clock rang out 1030 all in sequence and I felt his soul rush by my left ear as I looked at the bright sun outside.

He was still warm, but caved in, face hollowed by this final, slow illness that he had fought until the last. So full of life, he refused to speak of death. Instead, he kicked and punched, hearing stories of others living until one hundred on ensure, which motivated him to drink it, although the taste wasn’t to his liking. He told his niece to buy him milkshakes after I had told him how fattening they were, and loved A&W root beer shakes- I didn’t even know they made them.

I gently listened to his chest, finding the stethoscope difficult to manoeuvre over a bony manubrium, too many deep valleys between ribs that had long since lost any padding. No breath or heart sounds.

I saw his jaw move with gravity, relaxing into the left side of the bed, as though moving in his sleep and thought for one horrified moment that we had rushed him, then remembered that happens.

His eyes not yet glazed, not enough time passed, looked off into the distance, an unblinking stare with no pupillary reaction to the beautiful sunlight streaming over his soft white sheets.

I remember trying not to laugh at the wrong time as he told me a funny story- I didn’t know him long but he was a real comedian- when he put Vaseline on his teeth when he had them refit, because they felt too tight. I remember how happy he always was to see me walk in, ready to laugh at his next joke. Even though he was always so frail, he had a larger than life personality, with stories that would make a lumberjack marvel.

He lay there, peacefully. He went without any fuss, or any distress. Truly what we would consider a good death, although no death is ever good to those left behind. I carefully closed unblinking eyelids over deep black pools.

I will carry his memory now, and he has taken a part of me with him.

Compassion trumps all…

Healthcare and Humanity thinks this piece reflects the essence of healthcare.  Compassion. Kindness. Respect.

Congratulations Dr. Hacker for not only being such a wonderful doctor to your patients, but an inspiration for your colleagues.

“The first time I met Dr. Paul Hacker, I was working as a shift nurse in the community with a palliative patient who had ALS (Lou Gehrig’s Disease). Dr. Hacker sees a lot of patients  but he was able to remember almost every detail about this woman’s story as he sat on her couch talking with her. I recall thinking about how respectful he was by sitting by her side.  I remember admiring how thorough he was and how he didn’t refer to his notes when asking her detailed questions about how her mobility.  I remember that when he left, the family all started talking about how wonderful he was.

The next time I met Dr. Hacker, I was working as a nurse with Maycourt hospice. This is a hospice that deals specifically with end-of-life care (the last weeks or days of life) and Dr. Hacker would have patients  transferred there from their homes at the end. Every time he came to see one of them, he would make their days better– whether by reassuring family or talked realistically with the patient. As a nurse, working in the hospice was hard emotionally– I can’t say enough about how many times he would go out of his way to sit with us and make us laugh. He made volunteers laugh. He could even make his patients laugh. Every time he visited, we all got that reassurance. Families have even told us that when Dr. Hacker first visited them in their homes, he was the only person to have made the patient “truly laugh” since their diagnoses.

I think one of the best qualities your doctor can have is compassion. Being empathetic, patient and understanding toward people who are suffering is not something I see every day. Honestly, we all did a little celebratory dance of joy whenever Dr. Hacker was assigned to a patient in our care. We knew how well they would be looked after, and that meant a lot.

To one of the kindest, funniest doctor I know; who is 1000 times more amazing for bringing his dog to patients homes as well: thank you for looking after one of my friends’ dad recently. I got that same reassured and comforted feeling in my heart when I was told you were the doctor looking after him.

Thank you.

You are one of a kind and I am so blessed to have met you, learned from you, and worked with you.

Courtesy of  a colleague of Dr. Hacker who feels that it’s important to highlight a friend/colleague monthly that deserves a compliment.

 

Poetry as a Cadence of the Spoken Word..

                                                                                             

http://www.asiancha.com/content/view/1800/454/

Poetry is something that I have never indulged much in, and although I appreciate the written and spoken word.. I am an amateur at best when it comes to having an opinion.  I happened upon “Ancestral Worship”  a poetic journal quite accidentally. The book literally fell in my lap.  Mr David McKirdy, the poet, is a transplanted Briton with the soul of Hong Kong racing through his blood, faster than the bikes he rides.  He starts our journey with the title poem  “Ancestral Worship” where we feel his infusion/transfusion of the old Blood of China in a clinical and factual report..  That brings us to fragments of his life, put to verse from early childhood to the rebirth of the man that made Hong Kong his home.

Words make you feel.  And see.  And maybe not understand but somehow have something imparted in the soul.

Such is David McKirdy’s work.

Although I suspect if we were to ask  him, he would not consider it work.

David describes himself and his relationship with Hong Kong in a very modest manner that is in keeping with his demeanour.  ” I consider myself an Asian writer.  Hong Kong has always been a city of immigrants and I am simply one more that has been welcomed and made the city my home”  Having said that .. the depth of his verse belies but also celebrates that simplicity.

Healthcare and Humanity is fortunate to have the opportunity to share some of David’s work, both in his first anthology “Accidental Occidental” from 2011 and more recently “Ancestral Worship” published in 2014.  In both he expresses his experience with cancer with candor, sensitivity in an a manner that both belies and embodies reality. Poet, vintage car mechanic, dirt bike racer, ambassador, friend, sage, patient.

Please enjoy David McKirdy’s work and remember the Art of Medicine also is embodied in the patient.

I don’t believe in Cancer Cures

I met Audrey the first week after I graduated from Medical School.  I was now called Doctor, and the title felt shiny like a bright new copper penny, but also heavy and uncertain.  She came in through the Emergency Department as white as a ghost and short of breath.  Her blood count was very low and she had no white blood cells.  A Bone Marrow Test quickly determined that she had AML (Acute Myeloid Leukaemia). Audrey was a slim almost waif like older woman who wore dark red lipstick and an elegant neck scarf, even when she was forced into the thin blue cotton patient gown.  When we, “The Team”  walked into her room 24 hours later and told her that she had “Leukaemia” she looked at us straight in the eye and stated  “I don’t believe in Cancer Cures”.  The attending Hematologist was perplexed, and left the room with me remaining present and looking nervously at Audrey.  She asked me what I thought.  I told her that I thought we could make her better, and if we did nothing she was going to die.

And that was the start of our Patient Doctor Relationship. She decided to stay in hospital and be treated.  I was the intern rotating on the Hematology/Oncology service so I saw her every day of that month. The 31 long days from when she started her chemotherapy to the final day that she got to go home.  I would pop in to spend some time with her when I was on call in the hospital, and she would always save me some small treat if she was well enough to notice my presence.  Many evenings she was not well enough but would look at me and put on a  ghost like smile. I sat in her room with my books and studied when she slept.

The day I finished that rotation was the day Audrey got to go home.  She had had her post chemotherapy bone marrow test and all was clear.  She was in remission.  Giggling she said she was as “high as a kite”  as she put back on the dark red lipstick. She had a tiny package to give me.  There was no card, and I unwrapped it carefully.  Inside  was an small enamelled  fish charm to put on a necklace or bracelet.  I thanked her. Time passed and I kept the charm safe.  It sat on the bracelet that  my granny gave me when I turned twelve.

At the end of that internship year  Audrey came back through the Emergency Department.  Low blood again and no white blood cells.  Her leukaemia had entered again into an acute “blast” stage.  There was nothing more that could be done. She was dying.  I had seen patients die before, but never one that was so connected to me.  I was just learning how to have empathy without feeling every moment of pain personally.  And besides I didn’t want to lose that ability to feel the pain of my patients.

I couldn’t go in the room to say goodbye to her. I stood outside the door numbed with pain nervously fingering my little enamel fish.  I couldn’t even cry because it would have seemed unprofessional.  She died before I could say goodbye.  She didn’t suffer to my knowledge.  After she died I went in the room because the nurses asked me to pronounce her death.

That was 30 years ago…

I cried…(2/2)

Then the question came; how long do you think she has? A sister and a brother are on their way here tomorrow. I don’t know for certain, so much variability, but it could be a day, maybe two, I answered hopeful. I walked over to the bedside and checked her pulse, slow and weak. Then, I noted her breathing was changing, there were some apneic spells. I looked over to the daughter who seemed to know. Is she getting close, she asked? Yes, she is, I answered.

I stepped aside to allow them access to their mother’s bedside as the daughter moved to close the door to the room. She grabbed my coat sleeve and said she wanted me to stay. She indicated the bedside. I went to their mother, pulled the blanket off, and held her cool hand, noting the paleness and the cyanotic nailbeds. The son and daughter are next to me as they ask why the colour changes and I answer that her body is shutting down. She is getting closer.

They step outside the room to call their families to come and I am left alone with this brave valiant woman. I note that her breaths are further apart now. It seems like many minutes go by but likely only a few seconds before they return with everyone, tears streaming down their faces. I cannot feel her pulse, the right carotid is no longer pounding, and her breathing has stopped. How long has it been I wonder as the daughter asks if she is gone.  I wait a few seconds before turning to them all and announcing by nodding my head that she is gone. The daughter was nearest to me and she hugged me as I said I was sorry for their loss. As I left the room, I quickly patted the son’s arm as well. That’s when it started.

I could not hold back the tears quietly falling down my cheeks, much as I tried. The nurse and the support worker were coming up the stairs and down the hall; did I want a stethoscope to verify my diagnosis of death? No, that won’t be necessary. I know, I felt it. I made my way downstairs to the office, wiped my tears, and sat down to do the paperwork. The nurse came to see if I was alright. The son came downstairs and asked me if I was ok, too.

I am fine, I said. It has been a long time since I was at the bedside while someone is dying and I had forgotten how special this moment is. I expressed my appreciation; their family had allowed me this privilege after knowing me but a few minutes. You have a heart, the son said, as he hugged me and thanked me. Thank you, I said and meant it.

On my way out of the house, I saw the daughter again. She seemed to be coping well. She hugged me again, saying we are so used to doctors being so standoffish and strict. Thank you.

I was putting on my boots when the son came over and encouraged me to drive home safely. And the same to you. Walking to my car, the freezing rain, the cold, the slippery roads did not matter. I did not feel like I usually did after a call; I felt like I had just lived something very precious.

I cried…(1/2)

My family will tell you I cry easily. Bets are on when I watch a movie with them as to which scene will start the waterfall. But it was not a movie that made my cry the other night.

I am a coroner and I have attended thousands of deaths: at home, on the roadway, in the hospital, in the forest…but I do not cry there. Sometimes it is harder than others not to. I am expected to be the voice of reason and calm in often chaotic scenes. I do not disappoint; I do not cry there.

I am a family physician and I have attended upon thousands of people over more than thirty years: in their homes, in the office, at the hospital, and even on airplanes. Rarely have I come to tears with a patient, only after they have left will I allow the sadness of the news given to flood my mind. I am expected to be strong, calm, in charge, and I should know what to do; have a plan. I do not disappoint.

I practice palliative care in the home and at hospice. I attend deaths to say goodbye to the departed and the families; the latter needing the most attention. I offer words of empathy and sympathy; I remain calm. I try to lessen their distress but not their loss.

The other night…she arrived with her daughter and her son just before 4 o’clock. She is comfortable, the nurse told me, just letting you know she has arrived. I assured her I would be in later. It was 6:30 when I met them. The weather was turning nasty as I entered the hospice.  The door to their room was open, I noted, as I took off my boots. The daughter locked eyes with mine, offered a smile, inviting me in. I didn’t bother taking off my coat as I walked in and introduced myself. We shook hands and I met her brother sitting in the chair nearby. So, tell me about your mom, as I glanced quickly at the older woman settled in the bed and sleeping comfortably.

She told me much about her mother, how she had lived on her own, a full life before dizziness changed things. She invited her to come live with her a while as she recovered from the inner ear problem hampering her independence. Soon after, she realized that something was wrong, she was just too listless. After taking her to the local hospital, she was admitted and eventually, she was diagnosed with cancer that had spread to her brain. Treatment followed but it was not working and she was getting weaker. They said she was palliative earlier this month. I kept her at home as long as I could, the daughter said. But, she is not eating or drinking anymore. The nurses put in two ports for pain and seizure medications, and we needed help. We are all ready for hospice.

I listened to the story of this mother and grandmother who had obviously been cared for with much love. Her daughter was impressively well organized in her thoughts as she provided details; her brother added some details as well. They seemed to be working very well together; their mother was fortunate, I thought, as the son walked over to their mother, got a sponge swab wet with water and cleansed her lips and inner cheeks with ease while speaking to her gently. I observed the reaction from their mother, barely a moan, she was deeply asleep. She seemed to be breathing with some effort now.

 

 

His Final Gift

When my father died many people approached me to tell me about the small things he had done to change their lives..  They were apparently insignificant things as I never knew about them exactly.  Not accomplishments that would come up in general conversation, a curriculum vitae or at the end of an illustrious life, an obituary.  They were things like providing tutoring before a big exam, and other favours of that nature.  They were cumulative and I would hear repeatedly about these small gifts.

His final gift. He had Parkinson’s, and his world in the last couple of years of his life became increasingly restricted. His mobility suffered and at the end he suffered a fall resulting in a massive cerebral hematoma (traumatic stroke)  and brain death.  As a result he was able to give his final gift.

I signed the consent for organ donation as they turned off the life support.  I guess I wondered what would happen, but was a bit too numb to completely understand.  Time passed and I heard nothing.  His old gold watch for a while was his only tangible presence and I wore it 24 hours a day. It was like  having a childhood lovey, a talisman.  Eventually I had to relinquish it to my brother as it was not mine to keep; his final gift to my brother.

A letter came to me a year or more later from “Trillium Gift of Life”  . The letter was forwarded from the woman who received his liver.  I was a bit shocked that someone ended up with the liver of an elderly man, but I guess it was a good liver.  She was writing to thank us for his final gift.  She had just welcomed her first grand daughter into the world.  The year before she had been dying of liver failure secondary to “Primary Biliary Cirrhosis”.  She knew that her daughter was newly pregnant, but also knew she likely only had a few weeks left to live.  When he died he gave her back her life as well as gave her grand daughter a nana, bubbi, granny or whatever that special person is called in whatever culture.  His final gift of love.

 

 

Baby’s breath….

 

A baby was born last night and was not doing well.

The Pediatric Fellow warned me: “It can sometime take days for a newborn to die. Talk to the family. Talk them through the process. Make sure they understand.”

She paused, “”make sure you understand too because it’s going to be very hard on them…and on you…and everyone”

I reached for my pregnant belly. The stark contrast between my own situation–a baby alive and kicking inside of me–and the baby who was dying–was heart-breaking.

I wanted to run. But I couldn’t walk away.

As the Doctor on call, I left my busy family medicine clinic that Friday afternoon to go help. The neonatal team from McMaster had been there and left. They had tried everything–and despite their amazing, heroic measures–the baby was still dying.

So I was called. My job description: provide comfort care until the baby died.

When I became a rural doctor, I knew I was taking on many roles.  I work as a family doctor. I do anasthesia in the local hospital. I do house calls for the very sick and frail. I see kids.

I provide full cradle to grave care.

Palliative care is about providing comfort, grace and dignity at the end of life. Dying is a process and often takes time.  The goal is to ease suffering–for both the patient and the family.

It is one of the most personal, essential and humbling jobs that I do.

She was different. She was the first baby I would palliate.

I was introduced to the family. We talked through the plan, went through expectations. I reviewed what I could and couldn’t do.

I met the baby: a tiny, seemingly perfect newborn with tiny fists, tiny wrinkled feet and a head full of black hair.

My heart squeezed.

I stayed with the family all day–preparing them for what was coming, helping them understand what a normal baby breath was and what was a struggling gasp.

I left them in the evening to be with their baby girl, with them calling me anytime they needed me. Midnight, 3 a.m. I came whenever she gasped or struggled–provided her with medication to ease her discomfort and stayed until her breathing eased.

After each visit, I would go home and hug my own babies. Grateful for whatever mercy had brought them to me healthy, alive and whole.

It was a Sunday.

I was sitting in a rocking chair, holding her while she slept. The sun was warming my neck.

She released her last breath.

I gave her to her dad. I touched her mom’s hand.

None of us spoke. But we all wept.

I’ve lived a full life…

I met her my second week at my new practice.  A.W. was a few years older than me and had a great smile.  We had instant rapport. She was in to see me for abdominal pain.

Two weeks later, I got a report about her having emergency surgery. Oh no,  I thought as I reviewed the notes, but lucky for her they were able to operate in time …

I didn’t get to say what I had planned.  When she came in to see me a week later, we had the final reports.

“Adenocarcinoma.” Cancer. It was everywhere.

Stage 4, so by definition, not curable.

As the oncologists rushed to figure out the type of cancer and treatment options, our conversations became existential. How can a 35 year old, vegetarian Tibetan woman – who exercised, never smoked, didn’t drink or do drugs, meditated, and did volunteer work around the world for the poor – have stage 4 cancer?   There was no family history of cancer.  Why was this happening to her?

We talked about this over the next couple of years. We laughed, we cried, we shared stories as I walked with her through this journey. She went through multiple surgeries, mostly emergency as her cancer progressed and caused her pain or other problems.

In the end, I would visit her at home as a friend. She had a palliative care doctor to care for her physical needs now.  I once looked at her family photos on her bedside table and asked her “who’s this?” pointing to a beautiful young woman in the center – knowing as the words left my mouth, that of course, it was A.W. before the cancer had ravaged her body.

“I may only be 38 years old but I have lived a full life.”

Being A.W.’s family doctor has been one of the greatest privileges of my life.  She taught me that cancer may take her body, but it can never take her spirit.

And in the end, she still smiled.